Author: MM_ADMIN

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What are the 4 critical risks of investing in the Health and Human Services (HHS) space?

6-minute read

Many of our clients are investment professionals working in the health and human services space (including the full spectrum from angel to VC to equity firms). The article below is based on our experience working with investors who have succeeded in this space.

Risk 1: Failing to understand that seeking revenues in the Health and Human Services (space) creates a new set of challenges for your portfolio companies

One of the worst mistakes investors new to the space can make is to assume that strategies rooted in the commercial payer or Medicare Advantage space can be simply pivoted into the Medicaid space. The mistake is understandable, because few portfolio companies understand this risk and they do not know to communicate it to their investment partners.

Risk 2: Underestimating the Learning Curve

Understanding that commercial and Medicare strategies need to be dramatically altered to work in Medicaid is the first step. The next risk is underestimating the learning curve for Medicaid. Each state operates its own Medicaid program, and most benefit, operational and procurement decisions are done independent from federal operations. We have a saying in our space: “If you have seen one Medicaid program, you’ve seen one Medicaid program.” Besides the policy differences across states, each state has its own agency and stakeholder environment, and navigating these is extremely complex for HHS veterans. Finally, the regulatory environment for this space evolves constantly, and in ways that greatly impact revenue projections. For those new to the space, critical mistakes and loss of time are guaranteed.

Risk 3: Miss the Unique Complexity of the HHS Sales Cycle for Your Portfolio Companies

Many investors rely on the relational nature of other verticals for confidence in sales revenues. While relationships play an important role in the HHS space, most contracting is done using a defined competitive procurement process. This applies to both state agency and health plan contracts (though less so in health plans). Because of the regulatory and bureaucratic components, the sales cycle for this space is much longer and much more unpredictable than in other verticals.

Risk 4: Differences in pricing models

The Medicaid space has two key components that drive unique pricing models: A focus on the rate-cell capitation payments to managed care plans, and long-standing efforts to implement value-based payment models.

Medicaid health plans are paid a per member per month (pmpm) fee by states to manage different populations (such as diabatics or pregnant mothers). All the costs for care and management of each member must be funded by those rates or the plan loses money. Each plan thus thinks of all vendor solution costs in terms of pmpm. This type of pricing is not the norm for most portfolio companies operating in the commercial space, and it may take a large effort to structure pricing models in a way that will succeed in the Medicaid space. Most portfolio companies price solutions at an aggregate level and do not have a way to assign costs at the plan member level.

The second challenging part of HHS pricing models is the focus on value-based payments. Most Medicaid state agencies and health plans are required to place an ever-increasing amount of their payments to providers in what is called a “value-based” arrangement. While precise definitions of these models remain elusive, the critical risk is not being able to clearly tie a portfolio company solution to specific member outcomes. Vendors should also be prepared with standard risk sharing arrangements to offer to prospects in the Medicaid space.

How You Can Address The Risks of Investing in the HHS Space

In addition to your own research into this vertical, there are a few key tactics that can help you overcome some of the common challenges in the space.

  1. Engage a consulting firm with deep expertise in the space, but that also has a practice area focused on assisting investment professionals. We provide this type of assistance to our investment clients, and are happy to have a conversation anytime. If our services and expertise are a fit for your needs as you develop or execute your strategy, engaging with us is a simple process. If we are not the right fit, we are happy to make a referral to another firm who may be.
  2. Consider adding a vertical-specific market intelligence product to your toolkit. While there are multiple options for general investing market intelligence in the healthcare space, if you are considering (or already executing) an investment thesis tied to HHS-vertical revenues, the more specific your research sources, the better.

Reach Out

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Medicaid Concepts: Electronic Visit Verification

This is part of our Medicaid Concepts series, in which we provide a high level overview of key concepts in the Medicaid industry today.

What do we mean by electronic visit verification (EVV)?


Electronic visit verification (EVV) is a category of technologies and services used to validate that a visit actually occurred (usually in the member’s home). While EVV has been around for a long time, the 21st Century Cures Act made it mandatory for all state Medicaid programs by January 2020 for personal care services and January 2023 for home health services.

At a minimum, EVV systems must document:

  • Date of service
  • Location of service
  • Individual providing service
  • Type of service
  • Individual receiving service
  • Time the service begins and ends

What role does Medicaid play?


In addition to implementing required EVV systems, Medicaid agencies are in a unique position to leverage EVV data to improve member service provision. Medicaid agencies also play an important role in educating members on the benefits of EVV and reassuring those members that have privacy concerns related to GPS data tied to their home.

While EVV is primarily designed to prevent fraud in the Medicaid system, there are opportunities to use EVV data to improve care coordination and identify member quality gaps. The ability to use EVV to improve member outcomes is only beginning to be explored.

Explore further


https://www.medicaid.gov/federal-policy-guidance/downloads/cib080819-2.pdfhttps://www.medicaid.gov/sites/default/files/2019-12/evv-requirements-intensive.pdf

https://www.medicaid.gov/medicaid/data-systems/outcomes-based-certification/electronic-visit-verification-certification/index.html

https://medicaid.publicrep.org/feature/electronic-visit-verification-evv/

https://medicaid.ohio.gov/INITIATIVES/Electronic-Visit-Verification

https://medicaid.georgia.gov/programs/all-programs/georgia-electronic-visit-verification-evv

https://chfs.ky.gov/agencies/dms/dca/Pages/evv.aspx

https://dhhs.ne.gov/Documents/EVV%20October%20Slides.pdf

https://www.in.gov/medicaid/providers/1005.htm

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Biden picks Chiquita Brooks-LaSure to run Medicare, Medicaid

MM Curator summary

 
 

Biden’s has officially selected his nominee for the top CMS job.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

If confirmed, Chiquita Brooks-LaSure would lead $1 trillion agency in second-most powerful post at Health and Human Services Department

 
 

President Biden has selected Chiquita Brooks-LaSure to lead the Centers for Medicare and Medicaid Services, filling a major role in his health-care leadership team, according to four people who spoke on the condition of anonymity because they were not authorized to discuss the decision.

Brooks-LaSure served in the Obama administration as a senior CMS official who helped implement the Affordable Care Act’s coverage expansion and insurance-market reforms. She also worked on Capitol Hill as a Democratic staff member for the House Ways and Means Committee, building ties with then-Rep. Xavier Becerra, Biden’s choice to lead the Health and Human Services department and who sat on the committee at the time.

 
 

Clipped from: https://www.washingtonpost.com/health/2021/02/17/biden-medicare-chiquita-brooks-lasure/

 
 

 
 

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Aetna protests Oklahoma managed Medicaid picks: 4 things to know

MM Curator summary

The protest stage of the OK MCO procurement has begun, with Aetna batting first.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

Aetna Better Health of Oklahoma is protesting the selection of four other private insurers to manage Oklahoma’s Medicaid program, according to The Frontier.

Four things to know:

1. In late January, Oklahoma selected four health insurers to manage its Medicaid program, called SoonerSelect. The winners were Blue Cross Blue Shield of Oklahoma, Humana Healthy Horizons, Oklahoma Complete Health (Centene subsidiary) and UnitedHealthcare.

2. Aetna Better Health of Oklahoma lost its bid to manage the program. In a 51-page protest filed Feb. 12, Aetna claimed the bid process was flawed, according to The Frontier.

3. Specifically, Aetna claimed the Oklahoma Health Care Authority unfairly evaluated the proposals, used a flawed scoring system to select winners, and didn’t properly review the insurer’s entire proposal.

4. The contract winners are set to begin managing Medicaid benefits for the state Oct. 1. The contracts are worth about $2.1 billion, according to StateImpact Oklahoma. 

Clipped from: https://www.beckershospitalreview.com/payer-issues/aetna-protests-oklahoma-managed-medicaid-picks-4-things-to-know.html

 
 

 
 

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Federal government asks court to scrap challenge to Medicaid work requirements

MM Curator summary

 
 

Biden has asked SCOTUS to cancel a planned case on work requirements.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

SCOTUS NEWS

By James Romoser on Feb 22, 2021 at 9:12 pm

 
 

Elizabeth Prelogar, now the acting solicitor general under President Joe Biden, argues to the court during 2016. (Art Lien)

The Department of Justice asked the Supreme Court on Monday to cancel next month’s argument on the legality of Medicaid work requirements – a policy that former President Donald Trump promoted but is now being rolled back by the Biden administration. One of the states seeking to implement the policy, however, quickly opposed the federal government’s request, telling the justices that the dispute is not moot and should still be heard.

If the justices grant the request, it will be the third dispute this term to be nixed from the court’s docket as a result of a policy shift by the new administration. Earlier this month, the court called off arguments on two immigration issues – Trump’s method of funding his border wall and his “remain in Mexico” policy for people seeking asylum – after President Joe Biden abandoned the policies being challenged.

Biden’s top health officials similarly have begun unwinding a controversial health care initiative that encouraged states to require some Medicaid recipients to work as a condition for maintaining their health coverage. Among the states that received the Trump administration’s approval to impose work requirements were Arkansas and New Hampshire, but a district judge and the U.S. Court of Appeals for the District of Columbia Circuit declared those approvals illegal after finding that they would undermine the purpose of the Medicaid program, which provides insurance to 77 million Americans.

The Trump administration and the two states asked the Supreme Court to review the issue, and in December, the justices agreed to do so in a pair of consolidated cases, now known as Cochran v. Gresham and Arkansas v. Gresham. The Trump administration filed its brief defending Medicaid work requirements on Jan. 19, the day before Trump left office. The oral argument is scheduled for March 29.

That argument is no longer necessary, Biden’s acting solicitor general, Elizabeth Prelogar, told the justices in a seven-page motion on Monday. The Biden administration has “preliminarily determined” that work requirements do not serve Medicaid’s goals, Prelogar wrote. The Department of Health and Human Services has already rescinded a Trump-era letter setting forth legal justifications for the policy, and it has notified states that it may withdraw state-specific approvals. Moreover, Prelogar noted, the policy is, at least for now, practically defunct. That’s due in part to a COVID-19 relief bill in which states received extra Medicaid funding if they refrained from imposing any new eligibility restrictions in the safety-net program. Every state in the country took the deal.

In light of what she called the “greatly changed circumstances,” Prelogar asked the justices to cancel the argument and vacate the two D.C. Circuit rulings that are on review at the Supreme Court. The cases should be sent back to HHS so that agency officials can re-evaluate the Arkansas and New Hampshire proposals, Prelogar said.

The Medicaid recipients who are challenging the legality of the work requirements consented to the Justice Department’s request. New Hampshire “takes no position” on the request, Prelogar told the justices.

Arkansas, however, filed a brief on Monday evening opposing the request. The state noted that the Biden administration has not formally revoked the policy of permitting Medicaid work requirements – it has merely made a “preliminary” judgment that the policy is unsound.

“Preliminary proposals to rescind agency action do not moot challenges to or defenses of it,” Arkansas said in its brief.

The dispute, the state argued, thus remains a live controversy and continues to raise an important legal issue for the Supreme Court to resolve: namely, the scope of the federal government’s authority to allow states to enact experimental policies in Medicaid.

 
 

Clipped from: https://www.scotusblog.com/2021/02/federal-government-asks-court-to-scrap-challenge-to-medicaid-work-requirements/

 
 

 
 

 
 

 
 

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Congress Requires New Medicaid Payment Reporting

MM Curator summary

 
 

States will now have to report more information on Medicaid supplemental payments to providers.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

As part of the omnibus Federal appropriations bill enacted into law on December 27, 2020, Congress established new reporting requirements for states that make Medicaid supplemental payments. The new requirements follow on the heels of the withdrawal of a controversial proposed rule, which would have made more sweeping changes to Medicaid supplemental payments. As a result of the new law, the Centers for Medicare and Medicaid Services (CMS) will be developing a new reporting system for supplemental payments by October 1, 2021.

Withdrawal of Regulatory Proposal Mandating Extensive Reporting on Medicaid supplemental payments

More than a year ago, in November of 2019, CMS issued the Medicaid Fiscal Accountability Rule (MFAR), a proposed federal regulation that included a number of significant changes to enhance federal oversight and scrutiny over Medicaid supplemental payments. As part of the MFAR, CMS would have required states to report extensive information about all Medicaid payments made to each provider receiving Medicaid supplemental payments, on both a quarterly and annual basis, as well as information about the source of any non-federal share used to finance such payments. MFAR also proposed to cap the size of Medicaid supplemental payments, require reauthorizations every three years, and limit the permissible local funds that could be used to finance the nonfederal share of the payments.

Former CMS Administrator Seema Verma announced on Twitter in September 2020 that CMS would withdraw MFAR, citing “concerns that have been raised by our state and provider partners about potential unintended consequences of the proposed rule, which require further study.” MFAR was officially withdrawn in January 2021.

COVID Relief Bill Includes New Public Reporting Requirements

The law requires the Secretary of the Department of Health and Human Services (HHS) to establish a reporting system for each state that authorizes supplemental payments in its Medicaid State plan by the by October 1, 2021. All reports must be publicly posted on the CMS website.

The reporting required by the new law is not as extensive as had been proposed under MFAR, but the new administration will have some discretion when developing the reporting system. The state reports would need to explain the purpose and intended effects of their Medicaid supplemental payments, including how the payments are consistent with federal Medicaid requirements related to efficiency, economy, quality of care, and access to services. The reports will also describe the providers eligible to receive supplemental payments and the methodology used to calculate and distribute the payments. Finally, the reports must include assurances that total Medicaid payments to an inpatient hospital will not exceed federal upper payment limits, including a demonstration of compliance with applicable upper payment limits.

Scope of Medicaid Supplemental Payments

The law defines a supplemental payment as “a payment to a provider that is in addition to any base payment made to the provider” under the Medicaid State plan or a Medicaid demonstration authority, other than Disproportionate Share Hospital payments. Although this definition sweeps broadly, it does invite questions about whether certain state Medicaid payments are properly characterized as supplemental or base payments. Further, the bill only requires reporting as a requirement for making supplemental payments under a state’s Medicaid plan, raising the possibility that payments authorized under a waiver or demonstration program could be treated differently.

The new reporting system will help advance federal goals of improving the oversight and transparency of Medicaid supplemental payments, and could result in additional scrutiny being applied to those payments. Health care providers that receive Medicaid supplemental payments should carefully watch for forthcoming guidance on the new reporting system and be prepared to work with their state to submit required information.

 
 

Clipped from: https://www.natlawreview.com/article/congress-requires-new-medicaid-payment-reporting

 
 

 
 

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Nevada Medicaid enrolls record 810,000 residents

MM Curator summary

 
 

Nevada has a new record for Medicaid enrollment, and its nearly 15% higher than the previous record

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

 
 

Medicaid and Check Up are now serving a record number of people, surpassing 800,000. The previous record was set in 2018 at over 690,000.

Nevada Medicaid, the state- and federally funded health insurance program, has hit record enrollment, with one out of every four Nevadans currently being served by the program.

Medicaid and Check Up are now serving more than 810,000 Nevadans, and the increase is attributed to the pandemic and subsequent economic downturn.

“Medicaid services are always available, and people continue to reach out to us in their time of need,” Nevada Medicaid Administrator Suzanne Bierman said. “The fact is, when more people need assistance, Nevada Medicaid enrollment goes up.”

The previous record enrollment was 690,596 set in August 2018. Enrollment is expected to continue to climb with a new open enrollment period from Feb. 15-May 15 through Nevada Health Link, which opened up in response to an executive order from President Joe Biden.

Nevada Medicaid offers assistance for people who have lost their job or become too sick to work; supports minimum wage workers, low-income families, children, seniors and people with disabilities; offers financial protection for working families so that they do not face bankruptcy when struck by unexpected illness or suddenly need to go to the hospital; and makes health care possible in many rural communities.

To get started, apply at https://accessnevada.dwss.nv.gov/

Those whose incomes are slightly too high to qualify for Medicaid are encouraged to apply through Nevada Health Link, where residents may be eligible to receive financial assistance through subsidies or tax credits to help pay for monthly premiums. For more information, visit NevadaHealthLink.com or call 1-800-547-2927.

 
 

 
 

 
 

Clipped from: https://pvtimes.com/news/nevada-medicaid-enrolls-record-810000-residents-96111/

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Audit: N.C. Medicaid failed to confirm provider qualifications

MM Curator summary

A new NC audit showed the Medicaid agency has extensive problems with using banned providers.

 
 

The article below has been highlighted and summarized by our research team. It is provided here for member convenience as part of our Curator service.

 
 

North Carolina’s Medicaid agency fell short on ensuring doctors and other medical providers met licensing and ownership qualifications to serve patients in the program, state auditors declared Thursday.

The report from State Auditor Beth Wood’s office examined samples from among the 90,000 Medicaid providers in the state in 2019.

The performance audit found that the Division of Health Benefits, which is responsible for screening and enrolling providers, often failed to identify and remove those whose professional licenses has been suspended or terminated. The screening work is performed by a third-party contractor, the report said.

Licenses can be removed for actions like malpractice, Medicaid fraud or sexual misconduct. These failures placed some Medicaid patients at increased risk for substandard care and resulted in 21 unlicensed providers receiving more than $1.6 million in Medicaid payments. In one case, auditors said, a physician assistant whose license was suspended based in part on allegations regarding inappropriate exams of female patients continued to treat hundreds of patients even after the suspension.

Auditors also found the division and its contractor failed to verify the professional credentials of enrolled providers seeking to continue to provide services.

The credentials of only a handful of 191 approved providers within a sample had been verified, the report said. Six of the unverified credentials actually lacked the required professional credentials, auditors said, resulting in $11.2 million in Medicaid spending to the ineligible providers. Auditors attributed the failure to weaknesses in an automated credentialing process.

Department of Health and Human Services Secretary Mandy Cohen, responding to the audit in a letter attached by Wood’s office, agreed with the auditors’ findings. Recommendations include removing from the Medicaid program all providers lacking proper credentials to offer services.

Cohen wrote that Medicaid program leadership at DHHS, which oversees the Division of Health Benefits, would make the issues in the report “a top priority.” Many recommended changes have already been implemented, including more routine, manual reviews of medical license board announcements, she added. And an improved credentialing program should come online in 2023, she said.

While the potential overpayments listed in the report subject to recoupment is more than $13 million, state auditors pointed out the amount only covered those providers within the statistical samples reviewed.

“It does not include all overpayments that may exist in the entire population of payments made to Medicaid providers,” the audit said.

North Carolina’s Medicaid program offers services to more than 2 million state residents, largely poor children, older adults and the disabled. The program spent $16.7 billion in federal and state funds for the year ending June 30, 2020.

 
 

Clipped from: https://www.modernhealthcare.com/medicaid/audit-nc-medicaid-failed-confirm-provider-qualifications

 
 

 
 

 
 

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Medicaid Analyst job with AbbVie

 
 

AbbVie’s mission is to discover and deliver innovative medicines that solve serious health issues today and address the medical challenges of tomorrow. We strive to have a remarkable impact on people’s lives across several key therapeutic areas: immunology, oncology, neuroscience, eye care, virology, women’s health and gastroenterology, in addition to products and services across its Allergan Aesthetics portfolio. For more information about AbbVie, please visit us at www.abbvie.com . Follow @abbvie on Twitter , Facebook , Instagram , YouTube and LinkedIn .

I. POSITION SUMMARY:

Responsible for the administration and analysis of State Medicaid contracts including reviewing and validating submissions, processing and paying rebates, and analyzing quarterly utilization and rebate trends and variances. Manages responsibilities in accordance with various state & federal regulations including but not limited to: Section 1927 of the Social Security Act, the Omnibus Budget Reconciliation Act of 1990 and 1993, Section 602 of the Veterans Healthcare Act, and Sarbanes Oxley as well as internal policies and procedures.

II. PRIMARY JOB RESPONSIBILITIES:

 
 

  1. CONTRACT ADMINISTRATION/PROCESS REBATES: Review and analyze all contract fields and evaluate contract language to uphold integrity of the rebate processing system. Manage contract changes such as adding/deleting products. Review and analyze pricing in the contract systems; ensure accurate reimbursement in a timely manner; maintain proper contract files; monitor contract expiration report. Process Medicaid rebate Claims within the systems Medicaid Module for Federal Statutory Programs, State Supplemental, and State Pharmaceutical Assistance Programs (SPAPs). Resolve open disputes with states. Work closely with State personnel, internal customers, and finance and rebate teams. Maintain good customer relations.

 
 

 
 

 
 

  1. SYSTEM MAINTENANCE: Load/maintain all products, pricing and contract information in the Revitas Medicaid Module; ensure proper set-up, coverage, calculation and reimbursement of all programs & products. Perform system preparation for each quarterly rebate cycle including but not limited to, RPU calculations, new product baseline data, T-Bill rates, CPI-U indexes, calculation methods, etc. Work with internal & external IT support teams on system issues, upgrades and patches. Review, analyze and resolve price discrepancies with CMS and the states; follow-up and correct all issues related to processing claims or system issues.

 
 

 
 

 
 

 
 

  1. REPORTS & ANALYSIS: Compile necessary reports needed to support pricing disclosures; document explanations in file. Compile & distribute quarterly sales, trend, and rebate reports to internal and external customers. Use internal systems to compile data necessary to research specific price issues related to internal self-audit or government-initiated audits.

 
 

III. ADDITIONAL JOB RESPONSIBILITIES:

 
 

 
 

 
 

 
 

  • STANDARD OPERATING PROCEDURES: Update SOP’s as changes in law, business, systems, or processes dictate. Ensure proper compliance with Sarbanes Oxley controls; submit reports necessary to audit tests.

 
 

 
 

 
 

  • FILE MAINTENANCE/DOCUMENTATION: Compile and maintain files for quarterly submissions, contracts, etc.

 
 

Qualifications


IV. POSITION QUALIFICATIONS:


Education: BA/BS, or equivalent experience required


Experience: 2+ years business experience, preferably with a concentration in contracting, and Medicaid related activities or financial analysis


Knowledge, Skills, and Abilities

 
 

 
 

 
 

 
 

  1. Strong analytical, problem-solving and organizational skills
  2. Proficiency in Microsoft Excel
  3. Excellent analytical and organizational skills
  4. Ability to manage multiple tasks, priorities and timelines
  5. A self-starter who can work independently
  6. Functional knowledge of Revitas/Model N and Medicaid systems preferred

 
 

V. PHYSICAL REQUIREMENTS:


While performing the duties of this job, the employee is required to:

 
 

 
 

 
 

  1. Communicate effectively with internal and external individuals
  2. Use computer, phone and other related business machines
  3. Sit for prolonged periods of time
  4. Travel to/Attend meetings off company premises

 
 

 Clipped from: https://www.biospace.com/job/2252743/medicaid-analyst/?utm_campaign=google_jobs_apply&utm_source=google_jobs_apply&utm_medium=organic

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Center for Program Integrity (CPI)

 
 

Department of Health And Human Services
Center for Program Integrity (CPI)

Summary

This position is located in the Department of Health & Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), Center for Program Integrity (CPI), Division of Program Integrity Support Contracts.

As a Health Insurance Specialist (Program Contractor Management), GS-0107-11/12, you will use program knowledge to effectively plan, identify, and design contract requirements during the planning and awarding phase of acquisition(s).

Learn more about this agency

Responsibilities

  • Provide analytical support on policy issues and topics, research background information, the origin of laws, and the intended impact in order.
  • Use program knowledge to effectively plan, identify, and design contract requirements during the planning and awarding phase of acquisition(s).
  • Document performance with special emphasis on significant trends and items of interest in the management of contractor actions.
  • Manage, monitor, and oversee contractor transition activities.
  • Develop, implement, and maintain operational requirements, including standard operating procedures, as well as databases, to manage and analyze programmatic information such as routine and ad hoc report, deliverables, and programmatic documentation.

Travel Required

Occasional travel – 5% or less

Supervisory status

No

Promotion Potential

12

Requirements

Conditions of Employment

  • You must be a U.S. Citizen or National to apply for this position.
  • You will be subject to a background and suitability investigation.
  • Time-in-Grade restrictions apply.

Qualifications

ALL QUALIFICATION REQUIREMENTS MUST BE MET WITHIN 30 DAYS OF THE CLOSING DATE OF THIS ANNOUNCEMENT.


Your resume must include detailed information as it relates to the responsibilities and specialized experience for this position. Evidence of copying and pasting directly from the vacancy announcement without clearly documenting supplemental information to describe your experience will result in an ineligible rating. This will prevent you from receiving further consideration.


In order to qualify for the GS-12, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-11 grade level in the Federal government, obtained in either the private or public sector, to include: (1) Monitoring contractors that support in national health care delivery, quality, or payment programs and/or maintain health care program-related databases; (2) Conducting analytical studies by interpreting health care program issues related to contract administration functions; and (3) Coordinating responses to government inquiries regarding health care program issues requiring corrective action plans.


In order to qualify for the GS-11, you must meet the following: You must demonstrate in your resume at least one year (52 weeks) of qualifying specialized experience equivalent to the GS-09 grade level in the Federal government, obtained in either the private or public sector, to include: A. (1) Assisting in monitoring contractors that participate in national healthcare delivery programs and/or maintain program-related databases; (2) Participating as a team member in analytical studies by gathering, organizing, and interpreting policy, program, and/or operational issues related to contract administration functions; and (3) Developing responses to inquiries regarding healthcare program integrity issues.

– OR – B. Substitution of Education for Experience: possess a Ph.D. or equivalent doctoral degree or have completed three full years of progressively higher level graduate education leading to such a degree or I possess a LL.M in a related field of study, from an accredited college and/or university. One year of full-time graduate education is considered to be the number of credit hours that the school attended has determined to represent one year of full-time study. If that information cannot be obtained from the school, 18 semester hours will satisfying the one year of full-time study requirement. (TRANSCRIPT REQUIRED AT TIME OF APPLICATION)

– OR – C. Combination of Experience and Education: combination of specialized experience as described in “A” above and graduate education as described in “B” above. To combine education and experience, determine the total qualifying experience as a percentage of the experience required for the grade level. Then determine the education as a percentage of the education required for the grade level. Finally, add two percentages. The total percentage must equal at least 100 percent.


TRANSCRIPTS are required to verify satisfactory completion of the educational requirement related to substitution of education for experience and combination of experience and education. Please see “Required Documents” section below for what documentation is required at the time of application.


Experience refers to paid and unpaid experience, including volunteer work done through National Service programs (e.g., Peace Corps, AmeriCorps) and other organizations (e.g., professional; philanthropic; religious; spiritual; community, student, social). Volunteer work helps build critical competencies, knowledge, and skills and can provide valuable training and experience that translates directly to paid employment. You will receive credit for all qualifying experience, including volunteer experience.


Time-in-Grade: To be eligible, current or former Federal employees and current or former Federal employees applying under the VEOA eligibility who hold or have held a permanent General Schedule position in the previous year must have served at least 52 weeks (one year) at the next lower grade level from the position/grade level(s) to which they are applying.


Click the following link to view the occupational questionnaire: https://apply.usastaffing.gov/ViewQuestionnaire/11032441

Education

This job does not have an education qualification requirement.

Additional information

Bargaining Unit Position: Yes

Tour of Duty: Flexible

Recruitment/Relocation Incentive: Not Authorized

Financial Disclosure: Not Required


Full-Time Telework Program for CMS Employees: CMS employees currently participating in 100% Full-Time Telework Program may be eligible to remain in the program. If an employee in this program is selected, the pay will be set in accordance with the locality pay for the applicable duty station. The listed salary range reflects the locality pay assigned to the duty location(s) listed in the vacancy announcement. For more information about pay based on locality, please visit the Office of Personnel Management (OPM) Salaries & Wages Page.


Additional Forms REQUIRED Prior to Appointment:

  • Optional Form 306, Declaration of Federal Employment and the Background/Suitability Investigation – A background and suitability investigation will be required for all selectees. Appointment will be subject to the successful completion of the investigation and favorable adjudication. Failure to successfully meet these requirements may be grounds for appropriate personnel action. In addition, if hired, a reinvestigation or supplemental investigation may be required at a later time. If selected, the Optional Form 306 will be required prior to final job offer. Click here to obtain a copy of the Optional Form 306.
  • Form I-9, Employment Verification and the Electronic Eligibility Verification Program – CMS participates in the Electronic Employment Eligibility Verification Program (E-Verify). E-Verify helps employers determine employment eligibility of new hires and the validity of their Social Security numbers. If selected, the Form I-9 will be required at the time of in-processing. Click here for more information about E-Verify and to obtain a copy of the Form I-9.
  • Standard Form 61, Appointment Affidavits – If selected, the Standard Form 61 will be required at the time of in-processing. Click here to obtain a copy of the Standard Form 61.

The Interagency Career Transition Assistance Plan (ICTAP) and Career Transition Assistance Plan (CTAP) provide eligible displaced federal employees with selection priority over other candidates for competitive service vacancies. To be qualified you must submit the required documentation and be rated well-qualified for this vacancy. Click here for a detailed description of the required supporting documents. A well-qualified applicant is one whose knowledge, skills and abilities clearly exceed the minimum qualification requirements of the position. Additional information about ICTAP and CTAP eligibility is on OPM’s Career Transition Resources website at www.opm.gov/rif/employee_guides/career_transition.asp.


If you are unable to apply online or need to fax a document you do not have in electronic form, view the following link for information regarding an Alternate Application.

Read more

How You Will Be Evaluated

You will be evaluated for this job based on how well you meet the qualifications above.

Additional selections may be made for similar positions across the Department of Health and Human Services (HHS) within the local commuting area(s) of the location identified in this announcement. By applying, you agree to have your application shared with any interested selecting official(s) at HHS. Clearance of CTAP/ICTAP will be applied for similar positions across HHS.


Once the announcement has closed, your online application, resume, transcripts and CMS required documents will be used to determine if you meet eligibility and qualification requirements listed on this announcement. If you are found to be among the top qualified candidates, you will be referred to the selecting official for employment consideration. Please follow all instructions carefully. Errors or omissions may affect your rating.


Your qualifications will be evaluated on the following competencies (knowledge, skills, abilities and other characteristics):

  • Contracting/Procurement
  • Health Insurance
  • Oral Communication
  • Written Communication

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Background checks and security clearance

Security clearance

Not Required

Drug test required

No

Position sensitivity and risk

Non-sensitive (NS)/Low Risk

Trust determination process

Credentialing, Suitability/Fitness

Required Documents

The following documents are REQUIRED:


1. Resume
showing relevant experience; cover letter optional. Your resume must indicate your citizenship and if you are registered for Selective Service if you are a male born after 12/31/59. Your resume must also list your work experience and education (if applicable) including the start and end dates (mm/dd/yy) of each employment along with the number of hours worked per week. For work in the Federal service, you must include the series and grade level for the position(s). Your resume will be used to validate your responses to the assessment tool(s). For resume and application tips visit: https://www.usajobs.gov/Help/faq/application/documents/resume/what-to-include/

2. CMS Required Documents (e.g., SF-50, DD-214, SF-15, etc.). Required documents may be necessary to be considered for this vacancy announcement. Click here for a detailed description of the required documents. Failure to provide the required documentation WILL result in an ineligible rating OR non-consideration.


PLEASE NOTE: A complete application package includes the online application, resume, transcripts and CMS required documents. Please carefully review the full job announcement to include the “Required Documents” and “How to Apply” sections. Failure to submit the online application, resume, transcripts and CMS required documents, will result in you not being considered for employment.

Benefits

A career with the U.S. Government provides employees with a comprehensive benefits package. As a federal employee, you and your family will have access to a range of benefits that are designed to make your federal career very rewarding. Learn more about federal benefits.

Review our benefits

Eligibility for benefits depends on the type of position you hold and whether your position is full-time, part-time, or intermittent. Contact the hiring agency for more information on the specific benefits offered.

How to Apply

Your complete application package, as described in the “Required Documents” section, must be received by 11:59 PM ET on 02/25/2021 to receive consideration.


IN DESCRIBING YOUR WORK EXPERIENCE AND/OR EDUCATION, PLEASE BE CLEAR AND SPECIFIC REGARDING YOUR EXPERIENCE OR EDUCATION.


We strongly encourage applicants to utilize the USAJOBS resume builder in the creation of resumes. Please ensure EACH work history includes ALL of the following information:

  • Official Position Title (include series and grade if Federal job)
  • Duties (be specific in describing your duties)
  • Employer’s name and address
  • Supervisor name and phone number
  • Start and end dates including month, day and year (e.g. June 18, 2007 to April 05, 2008)
  • Full-time or part-time status (include hours worked per week)
  • Salary

Determining length of general or specialized experience is dependent on the above information and failure to provide ALL of this information WILL result in a finding of ineligible.

  • To begin, click Apply to access the online application. You will need to be logged into your USAJOBS account to apply. If you do not have a USAJOBS account, you will need to create one before beginning the application.
  • Follow the prompts to select your resume and/or other supporting documents to be included with your application package. You will have the opportunity to upload additional documents to include in your application before it is submitted. Your uploaded documents may take several hours to clear the virus scan process.
  • After acknowledging you have reviewed your application package, complete the Include Personal Information section as you deem appropriate and click to continue with the application process.
  • You will be taken to the online application which you must complete in order to apply for the position. Complete the online application, verify the required documentation is included with your application package, and submit the application.

To verify the status of your application, log into your USAJOBS account (https://my.usajobs.gov/Account/Login), all of your applications will appear on the Welcome screen. The Application Status will appear along with the date your application was last updated. For information on what each Application Status means, visit: https://www.usajobs.gov/Help/how-to/application/status/.


This agency provides reasonable accommodation to applicants with disabilities. If you need a reasonable accommodation for any part of the application or hiring process, please send an email to McQuail.Price@cms.hhs.gov. The decision to grant reasonable accommodation will be made on a case-by-case basis.


Commissioned Corps Officers (including Commissioned Corps applicants that are professionally boarded) who are interested in applying for this position must send their professional resume (not PHS Curriculum Vitae) and cover letter to CMSCorpsJobs@cms.hhs.gov in lieu of applying through this announcement. The cover letter should specifically explain how you are qualified for this position and draw specific attention to your resume that demonstrates these qualifications. In the subject line of your e-mail please include only the Job Announcement Number. In the body of your e-mail please include your current rank name and serial number. Failure to provide this information may impact your consideration for this position.
 

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Agency contact information

McQuail Price

Email

McQuail.Price@cms.hhs.gov

Address

Center for Program Integrity
7500 Security Blvd
Woodlawn, MD 21244
US

Learn more about this agency

Next steps

Once your online application is submitted, you will receive a confirmation notification by email. Your application will be evaluated to determine your eligibility and qualifications for the position. After the evaluation is complete, you will receive another email notification regarding the status of your application.


Within 30 business days of the closing date,02/25/2021, you may check your status online by logging into your USAJOBS account (https://my.usajobs.gov/Account/Login). We will update your status after each key stage in the application process has been completed.

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  • Fair & Transparent

The Federal hiring process is setup to be fair and transparent. Please read the following guidance.

Equal Employment Opportunity Policy

The United States Government does not discriminate in employment on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, membership in an employee organization, retaliation, parental status, military service, or other non-merit factor.

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Reasonable Accommodation Policy

Federal agencies must provide reasonable accommodation to applicants with disabilities where appropriate. Applicants requiring reasonable accommodation for any part of the application process should follow the instructions in the job opportunity announcement. For any part of the remaining hiring process, applicants should contact the hiring agency directly. Determinations on requests for reasonable accommodation will be made on a case-by-case basis.

A reasonable accommodation is any change to a job, the work environment, or the way things are usually done that enables an individual with a disability to apply for a job, perform job duties or receive equal access to job benefits.

Under the Rehabilitation Act of 1973, federal agencies must provide reasonable accommodations when:

  • An applicant with a disability needs an accommodation to have an equal opportunity to apply for a job.
  • An employee with a disability needs an accommodation to perform the essential job duties or to gain access to the workplace.
  • An employee with a disability needs an accommodation to receive equal access to benefits, such as details, training, and office-sponsored events.

You can request a reasonable accommodation at any time during the application or hiring process or while on the job. Requests are considered on a case-by-case basis.

Learn more about disability employment and reasonable accommodations or how to contact an agency.

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Clipped from: https://www.usajobs.gov/GetJob/ViewDetails/592126600